Elsevier

Journal of Pediatric Surgery

Volume 49, Issue 12, December 2014, Pages 1856-1860
Journal of Pediatric Surgery

PAPS Papers
Impact of newly adopted guidelines for management of children with isolated skull fracture

https://doi.org/10.1016/j.jpedsurg.2014.09.038Get rights and content

Abstract

Purpose

In an effort to standardize practices and reduce unnecessary hospital resource utilization, we implemented guidelines for management of patients with isolated skull fractures (ISF). We sought to examine the impact of these guidelines.

Methods

Patients with nondisplaced/depressed fracture of the skull vault without intracranial hemorrhage were prospectively enrolled from February 2010 to February 2014.

Results

Eighty-eight patients (median age = 10 months) were enrolled. Fall was the most common mechanism of injury (87%). The overall admission rate was 57%, representing an 18% decrease from that reported prior to guideline implementation (2003–2008; p = 0.001). Guideline criteria for admission included vomiting, abnormal neurologic exam, concern for abuse, and others. Forty-two percent of patients were admitted outside of the guideline, primarily because of young age (20%). Patients transferred from another hospital (36%) were more likely to be admitted, though the majority (63%) did not meet admission criteria. No ED-discharged patient returned for neurologic symptoms, and none reported significant ongoing symptoms on follow-up phone call.

Conclusions

Implementation of a new guideline for management of ISF resulted in a reduction of admissions without compromising patient safety. Young age remains a common concern for practitioners despite not being a criterion for admission. Interhospital transfer may be unnecessary in many cases.

Section snippets

Methods

Patients treated at our pediatric level I trauma center between February 9, 2012 and February 8, 2014 with a skull fracture identified using computed tomography were considered for study inclusion. Patients were screened and enrolled at the time of their treatment by a member of the study team, or identified after discharge using hospital information systems and ICD9 diagnoses codes. In either case, patients with a Glasgow coma score of 15 on arrival were considered eligible for enrollment,

Results

Eighty-eight patients met eligibility criteria for inclusion in the study. This represents 14% of all patients with a skull fracture, and 1.7% of all patients with any head injury treated at our hospital over the study period. Patient and injury characteristics are summarized in Table 2. The median age was 10 months (range: 18 days to 16 years). Fractures of the parietal bone were the most common type of fracture (56; 64%), and 15% of patients had fracture of more than one skull bone. Falls

Discussion

Though controversial, skull fracture is often considered a predictor of intracranial pathology in children presenting to emergency departments with minor head trauma [6], [8], [9], [10], [11], [12]. However, in children with ISF presenting with normal mental status and no intracranial pathology on initial radiologic evaluation, complications requiring specialized treatment are rare [3], [4], [5], [6]. Despite this, the majority of patients with ISF of the skull vault are hospitalized for

Conclusion

Implementation of a clinical treatment algorithm for the management of children with an ISF and normal neurologic exam on initial evaluation reduced admissions without compromising patient safety. Young age of the patient remains a common concern for practitioners when considering discharge. Our study also suggests that interhospital transfer may be unnecessary in many cases.

Acknowledgments

Center for Clinical and Translational Sciences grant support (CTSA 5UL1RR025764-02).

References (13)

There are more references available in the full text version of this article.

Cited by (22)

  • Pediatric Cranial Reconstruction

    2019, Facial Trauma Surgery: From Primary Repair to Reconstruction
  • A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children

    2018, Annals of Emergency Medicine
    Citation Excerpt :

    After screening title and abstracts for each of these, we identified 69 studies for full-text review. After a manual review, 21 studies were identified that met our final inclusion criteria.4-6,16-33 We describe the study designs and patient characteristics for each of the included studies (Table 1).

  • Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?

    2017, Clinical Radiology
    Citation Excerpt :

    Therefore, there is a service provision and economic impact for the hospital following the identification of simple skull fractures in infants and young children. Metzger et al.,12 implemented guidelines designed to reduce admission of children with simple skull fracture following blunt head trauma and reduced admission rates from 75% to 57% in their study in Salt Lake City, UT. Metzger et al. also noted that young age combined with the presence of skull fracture was a concerning feature for clinicians and that this often prompted hospital admission despite this not being indicated by their guidelines.

  • Observation for isolated traumatic skull fractures in the pediatric population: Unnecessary and costly

    2016, Journal of Pediatric Surgery
    Citation Excerpt :

    Although data supports early discharge from the emergency department in this patient population, there is a lack of published data guiding the management of this patient population. Our study found that the minority of our patients were directly released from the ED with follow up with their primary care physicians (22.5%) and that the majority (77.5%) were admitted for serial neurological examinations, despite evidence that these patients are at low risk for complication [14–19]. Our admission rate correlates with that of other studies looking at isolated skull fractures, in which 75-78% of the patients were hospitalized [14,17].

View all citing articles on Scopus
View full text